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SA N.J Q A Q U I N Environmental Health Department <br /> —COUNTY— <br /> Example: <br /> NIADE IN A HOME KITCHEN <br /> Permlt.N: 12345 <br /> Issued In county: County name <br /> Chocolate Chip cookies wilh walnuts <br /> Sally Baker <br /> 123 Cottage Food Lane <br /> An)uhere.CA 90..=X <br /> IngredlentV Enriched flour(wheat flour,macin,.rerluced iron.tlunniine. <br /> mononitrate,riboflavin and folic ncid),batter(milk,snit),chocolate chips <br /> (sugar,chocolate liquor,cocoa butter,butterfat(milk), nrolnnts.sugar,eggs. <br /> salt,artificial vanilla eximm bakingsoda. <br /> Contains:\\'hent,eggs,milk soy,walnuts <br /> Net\\'t.3 oz(85.0498) <br /> �For the'Issued In County"-Identify the furisdiction(city/county)where you are obtaining approval. <br /> 6. Disposal of Waste: <br /> Please check what type of treatment is used to dispose of waste <br /> 7 Public Sewer Service ❑ Private Septic System <br /> In the event of septic system failure or plumbing problem,you am required to notify San Joaquin County Environmental Health Department <br /> immediately. <br /> 7. Water Source: <br /> Pease Identify the water source to be used in Cottage Food Facility(check one box) <br /> 4 Name of Public Water System or Community Services District: <br /> ❑ Private Water Supply", Identify the source(well,spring, surface, etc.): <br /> Private Water Supply: Initial Water Quality Results <br /> Check boxes below if initial water testing has been completed. <br /> All testing must be done at a State Certified Laboratory. Either attach lab results or provide name of lab,date& <br /> results in space provided next to type of test. <br /> '(Testing frequency for transient Non-Community Water Systems after initial testing) <br /> ❑ Bacteriological Test(quarterly'): <br /> ❑ Nitrate Test(yearly'): <br /> ❑ Nitrite Test(every 3 years'): <br /> "Additional information may be required If food Is prepared from a home with a private water supply—check w0h local jurisdiction.n. <br /> 8. Food Processor Course: Initial if you agree to abide by the following: 1 ' 1 - <br /> Within 3 months of being approved to operate by the Environmental Health Department, please provide proof <br /> of completion of the California Food Handler course in lieu of the California Department of Public Health <br /> (CDPH)food processor course. <br /> For more Information see CDPH website www.cdph.ca.00vlprogramslPaeeslfdbCottaeeFood.aspx <br /> 4 of <br /> EHD 16-27 6129117 CFO REG/PERMITTING FORM <br />